Utah Prism Project Overview Medical Care Advisory Committee

Utah Prism Project Overview Medical Care Advisory Committee (MCAC) 4/17/2014 Presented By: The Division of Medicaid and Health Financing, Utah PRISM Project

Utah Prism Project (Utah MMIS Replacement Project) PRISM • PRISM is an acronym that stands for Provider Reimbursement Information System for Medicaid. • The name PRISM is intended to be symbolic of the clarity the new system will bring to Utah Medicaid users. PRISM signifies that we will continually strive to see and evaluate things from different perspectives and make necessary changes to improve our programs as we are looking from a new viewpoint. PRISM inspires notions of adaptability and innovation as we implement a new Medicaid system that will allow us to better serve our providers and members. • New Logo

Project Phases • Design, Development, and Implementation March 2013 to June 2017 – Four Releases – Release 1 (New Medicaid Website and Eligibility Lookup Tool) March 2014 – Release 2 (Healthbeat) August 2014 – Release 3 (Provider Portal and Enrollment) May 2015 – Release 4 (Remaining MMIS) May 2016 • Certification May 2016 to May 2017 • Knowledge Transfer May 2017 to May 2018

Release 1 – New Medicaid Website and Provider Eligibility Look Up Tool • The New Medicaid website – Updated Structure and Look and Feel – Enhanced Search Functionality – Utilizing a new content management system called “Drupal” – Includes functionality to facilitate outreach and communication to the providers, members and general public – Hosts the ’Medicaid Information Bulletins’ and the ’Medicaid Provider Manuals’ for download. Policy documents for Medicaid and Children's Health Insurance Program (CHIP) programs also available for reference • The Provider Eligibility Lookup Tool – Allows a provider to look up a client’s eligibility online. – This Eligibility Lookup Tool will be instrumental in facilitating our conversion from the current Medicaid eligibility document to the plastic Medicaid card in July.

Release 2 - Healthbeat • Health. Beat includes functionality to monitor and track Utah's health program goals continuously through Web-based scorecards that measure progress against targets and track the operational performance by receiving metrics on business processes using configurable dashboards • Health. Beat offers the required operational transparency by providing day-to-day transactional and summary views and reports for business processes and has the flexibility to define, monitor, measure operations, process metrics and automatically alert users when metrics exceed thresholds • For Release 2, Health. Beat will be fed information from the existing MMIS/MMCS system to create 6 web based Dashboards

Release 3 – Provider Portal • The Provider Portal will house data that is used to manage and maintain the status of all Providers paid through and/or reporting services rendered to DOH Clients. • Provider access includes: Self-service Provider enrollment, Self-service Provider maintenance, User maintenance (Provider and staff access based on role) • State access includes: Provider Enrollment, Provider Enrollment approvals, Provider Maintenance and Modification request approvals, Provider reports and correspondence • The State will also be able to manage and maintain the following: Add and manage Provider Types, Specialties, and Subspecialties, Add and manage Provider Indicators, Provider Task management, User maintenance (DOH staff), Provider inquiries

Release 4 – Medicaid Management Information System • The enhanced Provider Portal enables providers to submit and check claim status, submit and view status of prior authorizations, receive secure emails and correspondences as well as check Member eligibility • Through the Member Portal members are able to enroll in Managed Care Organizations (MCO’s), receive secure emails and correspondences as well as check procedure codes and eligibility • State integration with the portals will allow for monitoring of workflows, send / receive faxes /correspondence to / from Providers and Members, generate reports and create cases • Implementation of a Fraud and Abuse Management solution to analyze health insurance claims and to look for and report on indicators related to fraud, waste, abuse and overpayments

Release 4 Cont. – Medicaid Management Information System • Full implementation of the CNSI MMIS transfer system with modifications for Utah specific needs to support all MITA business areas including: – Acceptance of claims and encounters provides comprehensive tracking through the entire claim life cycle, including the receipt of a claim/encounter, adjudication, and final Remittance Advice (RA) or Encounter Transaction Results Report (ETRR) generation – Integrated Financial Management solution provides access to Accounts Payable, Accounts Receivable, Cash Receipts, Deductions/Lien Payments, 1099 Processes and interfaces with external systems such as ORS/OIG and FINET/PTS – Member records including demographics and eligibility are received from Work Force Services and used during claims processing and Managed Care enrollment – Support and integration into claims processing of provider requested Prior Authorizations (PA) – Third Party Liability (TPL) subsystem stores TPL insurance information which is used in claims processing and potential recoveries – Health. Beat pulls information from new system to allow for expansion of the web dashboards – Cognos Reporting tool supports federal reporting, and this solution provides data required for generating and assembling federal reports

Contact Info Jason Stewart (Project Director) Phone: (801) 538 -1940 Email: jasonstewart@utah. gov Aaron Cook (Deputy Project Director) Phone: (801) 538 -1941 Email: acook@utah. gov